Healthcare Provider Details

I. General information

NPI: 1447335823
Provider Name (Legal Business Name): JEFFREY M WALCZYK STUDENT INTERN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 TUNXIS HILL ROAD
FAIRFIELD CT
06825
US

IV. Provider business mailing address

527 TUNXIS HILL ROAD
FAIRFIELD CT
06825
US

V. Phone/Fax

Practice location:
  • Phone: 203-333-7788
  • Fax: 203-366-7566
Mailing address:
  • Phone: 203-333-7788
  • Fax: 203-366-7566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number001716
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: